Contrast NephropathyContrast Nephropathy

Intern 黃賢能

1. Kandzari DE. Contrast nephropathy : an evidence-based approach to prevention. American Journal of Cardiovascular Drugs. 3(6):395-405, 2003.

2. Murphy SW. Contrast nephropathy. Journal of the American Society of Nephrology. 11(1):177-82, 2000 Jan.

3. Birck R. Acetylcysteine for prevention of contrast nephropathy: meta-analysis. Lancet. 362(9384):598-603, 2003 Aug 23. 805 cases

4. Curhan GC. Prevention of contrast nephropathy. JAMA. 289(5):606-8, 2003 Feb 5.

5. Guitterez NV. Determinants of serum creatinine trajectory in acute contrast nephropathy. Journal of Interventional Cardiology. 15(5):349-54, 2002 Oct. 95 cases

6. Durham JD. A randomized controlled trial of N-acetylcysteine to prevent contrast nephropathy in cardiac angiography. Kidney International. 62(6):2202-7, 2002 Dec. 79 cases

7. Kini AS. Changing trends in incidence and predictors of radiographic contrast nephropathy after percutaneous coronary intervention with use of fenoldopam. American Journal of Cardiology. 89(8):999-1002, 2002 Apr 15. 260 cases

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9. McCullough PA. Prediction and prevention of contrast nephropathy. Journal of Interventional Cardiology. 14(5):547-58, 2001 Oct. 150 cases

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ContrastContrast

Oil-soluble:

Dionosil: bronchogram

Lipiodol: TAE, lymphangiographyWater-soluble:

Ionic high-osmolarity: 900 osmo/kg

Ionic low-osmolarity: 500 osmo/kg

Non-ionic: 300 osmo/kg

ContrastContrast

Excretion: 100% from kidney80% by glomerular filtration20% by excretion from renal tubuleHalf life: 20 min (Ccr > 70 ml/min)

Contrast NephropathyContrast NephropathyDiagnosis:

A rise in serum creatinine of at least 0.5 (1) mg/dL within 48 h of contrast administration

Other causes of acute renal failure must be excluded

Clinical FeatureClinical Feature

Prerenal type acute renal failureOnset: within 24 to 48 hPeak: 3rd to 5th daysResolution: within 7~14 daysTransient

Risk FactorRisk Factor

Advanced age (> 65 y/o 1,9)Preexisting renal disease (CRI: CT: 8%

~28% 3, Angio: 15~40% 8) DM (20~50% 7,10)Dehydration 2,9

High contrast dose (neg:3 )Ionic, high-osmolar contrast media 1,2,4

PathophysiologyPathophysiology

Vasoconstriction: Endothelin-1Immune responseNephrotoxicity: free radicle

PreventionPrevention

Calcium channel blocker 4

Atrial natiuretic peptide (ANP)Furosemide 4,5,11

Mannitol 5,11

Dopamine 5

Endothelin-receptor antagonistDialysis 4

PreventionPrevention

0.45% saline 3,9,11

N-Acetylcysteine (NAC) 3,10

Acetylcysteine + hydration in chronic renal insufficiency 10

0.45% Saline0.45% Saline

Slightly Volume-expandedHigh urine output (>150 ml/hr 11)Mannitol, crystalloid 11

N-Acetylcysteine (NAC)N-Acetylcysteine (NAC)

Anti-oxidantNAC + NO ---> S-nitrothiol (a potent vas

odilator)Increase the expression of NO synthase

Fenoldopam (Corlopam)Fenoldopam (Corlopam)

Selective dopamine-1 (DA-1) receptor agonist Fenoldopam: Cr>2 (incidence<4% 7, 4.7% vs. 19% 8)

0.1 mcg/kg/minute 1~2 daysVasodilationAnti-hypertension

ConclusionConclusion

Risk of contrast nephropathy could be reduced by

Selection Preparation

SelectionSelection

No! Wait!Age > 65 y/oPreexisting renal disease: Cr > 2.5 Uncontrolled DMDehydrationPrevious contrast nephropathy

SelectionSelection

It dependsHeart failure, hypoalbuminemia, liver failureUncontrolled hypertensionOngoing infectionDiscuss with ---Lower contrast doseNonionic, low-osmolar contrast media

PreparationPreparation

0.45% saline, 1ml/kg/hr

N-Acetylcysteine,600mg bid po*2 days

12~24 hr 12 hr

Fenodolpam,0.1 mcg/kg/min

Mannitol, crystalloid

PreparationPreparation

Follow up BUN, Cr for 3~5 daysControl hypertension, infectionDialysis: can NOT prevent contrast

nephropathy

Thanks!Thanks!